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This is a weighty tome, which is appropriate considering the serious subject matter- sexual offenders and their treatment, prognosis and etiology. There are thirty chapters under eight sections covering areas like the Neurobiology / Neuropsychology of sexual offending; their Assessment and Diagnosis and their Treatment. These general sections are complemented by work on Juvenile offenders, Special Populations and Forensics.
The book opens with an introductory essay by Peter Fagan, who works in John Hopkins University. He asks how might we determine "normal" in relation to sexual behavior. He offers a framework into which to fit sexual behavior. Is "abnormal" behavior a consequence of a disease of some kind-the obvious example being of the behavior sometimes seen in patients in the Manic phase of Bi-Polar or in other floridly psychotic states? His next category is what he calls the Dimension perspective i.e. how does this person's behavior fit with a comparable "control" population? He adds a rider to these neat solutions by pointing out how much variance can be found within different communities. Thus the incidence of intercourse in couples aged 20 will vary to that of a couple in their 50's. And beyond this, the activity levels of a couple in their 20's might well vary depending upon the type of work they do; whether they are in an urban or rural community etc. The list of variables and their effects is long. And in the end it is this approach that is limiting. One might record that X number of individuals engage in sexual behavior with children. Or that Y number of young men engage in sexual activity with pensioners. These are simply facts of life. What one needs is a way for any society to decide what is acceptable and what is not. (And even here one runs into the classic debate about social relativity. Are there some behaviors that should be anathematized in any society? Can it ever be acceptable for a baby to be subjected to sexual behavior? Is rape ever acceptable? Can it ever be right for an individual to have sex with a corpse? If so, who makes this decision? Fagan suggests that science alone is an inadequate guide. "Not to include the disciplines of ethics, philosophy, and theology into the discussion of sexual normality is to reduce the question to skills of the scientific disciplines. Many will be content, even praise, that limitation. However, this author believes that the fullest exploration of human sexuality requires not only science, but also wisdom. For this we must turn to our wisdom traditions for assistance." (P.11) This takes us some way towards a morality of sexual behavior and a context in which Law may be made. (The nearest "Law" that I could come up with was that a guiding principle of sexual behavior should be that it is consensual. But it doesn't take much skill to find the flaws in this rule. Perhaps this is why this volume of essays eschews writing about morals or moral behavior and limits itself to the issues set out in the title.)
The next chapter, by Gregory Lehne, outlines some of the behaviors that have been or are currently, classified as paraphilic (abnormal sexual behavior). Under "A" he lists 28 activities covering such behaviors as acoustophilia -arousal by sounds; acrotomophila and apotemnophilia - amputee partner or self. (A "Google" search for acrotomophilia gave 95, 000 hits including a forum; a Wiki and videos. And that for an activity that I had never heard about.) The list becomes almost comical. There are recognized terms for those who are attracted a woman with a penis (andromimetophilia); those who are sexually aroused by a partner of a different height (anasteemaphilia) etc., etc. Being aroused by sounds does not seem to be too problematic; another activity, autonephiophilia (a love of filth or obscenities) might be more difficult although I did discover a shirt maker who will make an outfit to appeal to a range of paraphilic tastes! The core of his essay, however, is to illustrate the relative emotional poverty of paraphilics. He takes the idea of Lovemaps and explores their use by paraphilics. A Lovemap is, "... the development or template in the mind or brain depicting the idealized partner and program of sexuerotic imagery or behavior." (P.14) Lovemaps, he continues, "... can be thought of like a mental map composed of many different terrains and political/ social territories. Some individuals' Lovemaps include vast areas, while others are more limited in scope- some people have a world of possibilities while others have a small village of choices to explore." (P.14) (It was interesting and rather heartening to read Lehne pointing out that the Internet may be a source of creative sexual exploration. It may provide a safe environment in which to explore different areas of one's Lovemap. But he concludes his paper by commenting that "Paraphilias are vandalized lovemaps characterized by very high specificity of sexual content and high sexual drive or motivation." (P.24)And that the Web can provide a reinforcement of these drives that might otherwise not be able to be so easily nurtured.
Langevin discusses the neuro-psychology of sex offenders, commenting that many sex offenders have "... significant deficits that may be related to the etiology of the sexual disorders they suffer." (P.33) lt is unclear what might cause these deficits although one wonders about the early attachment patterns of sexual offenders. And if there is neurocognitive damage, to what extent do we consider these individuals to be accountable for their actions? Should we lock them away in a prison or attempt some kind of therapeutic work with them? The chapters on treatment make for fascinating reading. These chapters look at the three main attempts at treatment which are physical, psychological, and pharmacological. Physical treatment is orchiectomy, strictly speaking, the removal of one or both testes. (The authors of this chapter make it clear that this differs from the broader term "castration" which has been used "... for control, domination, punishment, mutilation, and political reasons... since antiquity". (P.171) in their view, orchiectomy is a specific surgical intervention for a specific purpose. They cite a recent meta-analysis by Losel and Schumucker (2005) which reviewed 69 studies "... and found that surgical castration and hormonal medication showed larger effects on sexual recidivism than psycho-social intervention." (P.171) This left me wondering how I would feel as a sex offender if this was an option offered to me. Would I feel relieved because the chances of my reoffending were now much reduced or would I feel that I was only being given symptomatic relief without any attempt being made to help me understand my behavior? And this dichotomy in itself raises questions about why individuals offend. And how much "choice" do I have about my conduct?
This issue of what it is that one treats is touched on by Saleh in his paper on pharmacological treatments for paraphilia. He notes that to prescribe "... a medication to a paraphilic sex offender that has little-to-no real impact on his or her underlying paraphilia could have devastating consequences for both the offender... and the public at large." (P.201) Notwithstanding this rider, Saleh does recommend the use of some medications, notably those that lower testosterone levels which, he says, "... reduce the frequency, severity, and intensity of paraphilic symptoms within a short period of time". Pharmacological treatment, he notes, parallels the efficacy of orchiectomy in reducing rates of recidivism. One is now left with psychological treatment-a chapter that I found encouraging, but that might reflect my naïve faith in the value of psychological interventions.(I have never worked this sexual offenders only, occasionally, with adult survivors of CSA. Thus my optimism is not, necessarily, critically informed!)
Marshall, Serran, and O'Brien have written on psychological treatment. They begin their chapter with a brief overview of the various theories about the psychological underpinnings of paraphilia and the necessary outcomes for these models to be effective. The early psychological work aimed simply at changing sexually deviant behavior, the assumption being that classical conditioning was what prompted paraphilic behavior and kept it alive. So, presumably, classical conditioning could be used to re-direct deviant sexuality. (Having recently watched "A Clockwork Orange" it is hard not to be very skeptical about his view of human behavior. Nor to be skeptical about the efficacy of Pavlovian techniques in bringing about lasting change.) The model that these workers espouse is a variation on Motivational Interviewing – the Good Lives Model. The aim of this program is not only to prevent relapse and to teach risk avoiding behavior but to help an offender to develop positive life skills. They quote research that shows that "... human's characteristically seek what has been called a 'good life'... made up of the pursuit of a list of needs covering various areas of life functioning (e.g. knowledge, mastery, autonomy, happiness, sexual satisfaction.) ... sexual offenders commit their offences in the vain hope of achieving some or all of these goals..." (P.161) The good Life model proposes to help offenders to learn how to achieve these common goals in an appropriate way. And as their colleagues in pharmacology and surgery, Marshall et al cite studies that show the efficacy of this model. (We now need a Meta review of all the Meta studies purporting to demonstrate the efficacy of any given intervention with sexual offenders!)
As this review shows, there is a wealth of literature about sex offenders. This book is probably one of the most comprehensive. Each chapter comes with an extensive set of references to other work so one could simply delve deeply into any single aspect of sex offending. Trying to grasp the whole scope of this volume of essays is very demanding-and inadvisable. (Much better to use it as a base camp from which to plan one's major expedition into the field of paraphilia.)
In closing, whilst I found this book fascinating and was intrigued by the various discussions, I kept on coming back to something more personal. Those who have contributed to this book all work with a group of patients who do not immediately evoke one's sympathy. One is sympathetic to any obvious victim of sexual offending-a rape victim, a child who has been sexually abused, etc. Yet the "unseen" victims here are also the perpetrators. My own Lovemap is a conservative place, peopled with desires that are easily and safely satisfied. I am not sure how it would be to live in a "love country" populated with desires that are dark and dangerous and put others at risk.
© 2009 Terry Burridge
Terry Burridge is a Senior Lecturer in Mental Health Nursing at Buckinghamshire New University. He has spent most of his professional life as a psychiatric nurse and now spends considerable time and energy trying to inspire future psychiatric nurses to be the best kinds of nurses that they can be! He is very much influenced by psychoanalytic thinking and sees analytic theory as offering a valuable critique to many other areas of human activity. He can be contacted at [email protected]